Small cell neuroendocrine carcinoma of the urinary bladder. A clinicopathologic study with emphasis on cytologic features

Urinary tract cytology showing variant morphology and divergent differentiation

Urothelial carcinoma represents a diverse group of tumours with distinct histologic subtypes, each exhibiting unique cytomorphologic features, architectural growth patterns, and/or well-developed aberrant differentiation. In fact, there are more than 13 subtypes of urothelial carcinoma recognized in the 2022 WHO classification of tumours in the urinary tract. The identification of these subtypes is crucial for an accurate diagnosis of urothelial carcinoma, and many have important clinical implications. Variant/divergent features may coexist with conventional high-grade urothelial carcinoma (HGUC) or present with 100% variant morphology. In urinary tract cytology (UTC), urothelial carcinoma can display divergent differentiation, such as squamous, glandular, or small cell carcinoma differentiation. The use of cell block preparations and immunohistochemistry with available residual urine can enhance diagnostic accuracy. On the other hand, identifying urothelial carcinoma variants, including nested, micropapillary, and plasmacytoid subtypes, poses significant challenges in UTC. Many cases of these variants are only detected retrospectively after variant histology has been established from resection specimens. Moreover, some variants exhibit features inconsistent with the diagnostic criteria for HGUC according to the Paris System for Reporting Urinary Tract Cytology. Nevertheless, the rarity of pure variant morphology and the occurrence of some false negatives for these variant cases are essential to maintain the specificity of UTC overall. This review covers the histology, cytomorphology, and important clinical aspects observed in urothelial carcinoma exhibiting divergent differentiation and various urothelial carcinoma variants detected in UTC.

Challenges and opportunities in the management of non-urothelial bladder cancers

Urothelial carcinoma accounts for approximately 90% of all bladder cancer diagnoses. Localized, muscle-invasive disease is often managed with a multidisciplinary approach including either neoadjuvant chemotherapy (NAC) followed by radical cystectomy or concurrent chemoradiation, whereas multiple immunotherapies and novel antibody drug conjugates have recently joined platinum-based chemotherapy as standard of care therapy for metastatic disease. However, the clinical trials leading to these standards often require majority if not complete urothelial histology for eligibility. As many as one quarter of patients diagnosed with bladder cancer will have either divergent differentiation of their urothelial carcinoma or an alternate epithelial tumor such as squamous cell carcinoma, adenocarcinoma, or small cell carcinoma; even more rare are non-epithelial tumors such as sarcoma. The rarity of these diseases and their general exclusion from treatment within prospective clinical trials has created a challenging situation where treatment plans are often derived from case series or extrapolated from other disease types and outcomes are poor compared to pure urothelial carcinoma. In this review, we summarize the existing data on the diagnosis and treatment of epithelial, non-urothelial bladder cancers including adenocarcinoma, squamous cell carcinoma, and small cell carcinoma in their localized and advances stages. We will also review the current clinical trial landscape investigating novel approaches to these diseases.

An Approach to Nonurothelial Malignancies of the Urinary Bladder in Urine Cytology

Urine cytology is an economical and convenient method of triaging patients who present with urinary symptoms as well as surveying those who have previously been diagnosed with urothelial carcinoma for recurrent or persistent disease. While the vast majority of malignancies diagnosed in urine cytology are urothelial carcinomas, it is important to recognize nonurothelial elements to inform patient prognosis and raise the possibility of involvement by a urothelial carcinoma variant, nonurothelial malignancy of the bladder, or a nonbladder primary, which may alter patient management pathways. As such, becoming familiar with morphologic features of nonurothelial malignancies in urine cytology as well as their related clinical risk factors, radiologic and cystoscopic features, differential diagnostic considerations, and the utility and pitfalls of ancillary tests can facilitate optimal patient care.

Small cell carcinoma of the upper urinary tract and factors associated with progress survival: a systematic review and pooled analysis

INTRODUCTION

Little is known about small cell carcinoma of the upper urinary tract (UUT-SCC), the aim of this study is to identify the risk factors in relation to survival of patients with UUT-SCC.

EVIDENCE ACQUISITION

Literature search on UUT-SCC was performed in databases including MEDLINE, EMBASE, Wangfang, and CNKI. Studies were eligible for inclusion if outcomes of patients with histopathologically confirmed UUT-SCC were reported. The relevant data on clinic, pathology, and therapy were collected. Progress survival was evaluated using the Cox regression model with the robust sandwich estimates of the covariance matrix.

EVIDENCE SYNTHESIS

There were 55 eligible publications identified, contributing 76 patients in total. The median of overall survival (OS) was 14 months. In univariable analyses, pathological stage and platinum-based chemotherapy regimen were associated with OS (pT3-pT4 versus pT1-pT2, HR=3.228, P=0.005; other chemotherapies versus platinum-based, HR=6.249, P=0.035). The median of cancer-specific survival (CSS) was 15 months. In univariable analyses, pathological stage and platinum-based chemotherapy regimen were associated with CCS (pT3-pT4 versus pT1-pT2, HR=3.332, P=0.004; non-platinum based versus platinum-based, HR=7.784, P=0.025).

CONCLUSIONS

In multivariable analyses, no variables were associated with OS and CSS. UUT-SCC is a rare tumor characterized by an aggressive clinical course. Pathological stage and platinum-based chemotherapy regimen are the most important factors related to OS and CSS.

Primary small-cell neuroendocrine carcinoma of the urinary bladder: A rare case and a review of the literature

Primary small-cell neuroendocrine carcinoma (SCNEC) of the urinary bladder is a rare tumor characterized by poor differentiation and high aggressiveness. Only ~150 cases have been reported in the literature to date. We herein present a case of an 87-year-old man who presented with hematuria and was found to have an ill-defined mass in the urinary bladder on computed tomography and cystoscopic examination. On pathological examination following tumor biopsy, the mucosa of the bladder wall was found to be extensively infiltrated by neuroendocrine carcinoma, positive for CD56 and synaptophysin and negative for epithelial membrane antigen, consistent with SCNEC of the urinary bladder. The patient refused further surgical treatment and succumbed to the disease 2 months after the diagnosis. In the present study, this rare case of primary SCNEC of the urinary bladder is presented, along with a discussion on the clinical presentation, immunohistochemical and cytomorphological characteristics, management, biological behavior and prognosis of this disease.

Small Cell Carcinoma of the Urinary Bladder. A Clinicopathologic Study of Five Cases

Aims and Background

Small cell carcinoma of the bladder (SCCB) is a rare entity characterized clinically by an aggressive behavior with a high incidence of systemic metastases. We report the clinicopathologic findings of five cases.

Methods

We reviewed five consecutive patients with SCCB treated at our institute. In each case the following clinical data were recorded: age, sex, presenting symptoms, endoscopically determined location of the tumor, clinical staging, node involvement (if any), site of metastases (if any), treatment, follow-up and outcome.

Results

There were four male and one female patients, age range 42 to 68 years, mean 57.6 years. The clinical presentation was not different from conventional transitional cell carcinoma, with hematuria being the most frequent complaint (four cases). Microscopic examination revealed oat cells in three cases and an intermediate variant in one. At the time of diagnosis the tumors were staged as T3bN2M0, T2N2M0, T4N0M0, T3aN0M0, and T2N0M0. Primary therapy consisted of radical cystectomy alone (one case), transurethral resection (TUR) alone (one case), TUR with chemotherapy (two cases), or TUR with chemotherapy and radiotherapy (one case). Four patients died of progressive disease, with survival from the time of diagnosis ranging from 7 to 16 months (mean, 12.2 months). One patient died of myocardial infarction (unrelated to the primary disease) one month after diagnosis.

Conclusion

Our study indicates that primary small cell carcinoma of the urinary bladder is as aggressive as its pulmonary counterpart and the overall prognosis of this tumor is very poor.

Cytomorphologic and Immunophenotypic Profile of a Cohort of Small Cell Carcinoma of the Urinary Bladder

BACKGROUND

The incidence of primary small cell carcinoma (SCC) of the urinary bladder is extremely rare. We sought to analyze the cytologic and immunophenotypic features of SCC of the urinary bladder in urine and reassert the importance of cytologic examination of urine specimens for diagnosis of this tumor.

METHODS

We studied the clinical and cytomorphologic features in the presurgical urine specimens (4 voided urine and 2 bladder-washing specimens) of histopathologically and immunohistochemically proven cases of SCC of the urinary bladder.

RESULTS

There were 6 cases, all males, with an age range of 61-81 years. On cytologic and histopathologic examination, typical SCC morphology was present in all cases. On immunohistochemistry, synaptophysin and CD56 were positive in all 6 cases, while chromogranin was positive in only 3. The Ki-67 labeling index ranged from 30 to 100%.

CONCLUSIONS

SCC should be kept in the differential diagnosis, when high-grade urothelial carcinoma is suspected in a urine cytology specimen, as this distinction has important therapeutic and prognostic implications. Therefore, a careful observation and, if required, the use of an appropriate immunocytochemical panel on the presurgical urine specimens can lead to a correct diagnosis.

Small cell carcinoma of the urinary bladder: changing trends in the current literature

Background Extrapulmonary small cell carcinoma (SmCC), also known as oat cell carcinoma or small cell neuroendocrine carcinoma, is characterized by an aggressive clinical course with early metastasis pattern and a short life expectancy. So far, there is no prospective, data-based case-control study due to its low incidence. The purpose of this paper is to discuss the epidemiology, morphopathology, clinical characteristics, differential diagnosis and treatment of bladder SmCC in the light of the literature. Scope PubMed and American Society of Clinical Oncology Meeting abstracts were searched according to the following keywords: 'extrapulmonary SmCC', 'bladder cancer', and 'therapeutic approach'. The last search was performed on 1 October 2015. Some additional papers were determined by reviewing references of the appropriate articles. Most of the data regarding small cell carcinoma of the urinary bladder (SmCCB) were found to be based on the retrospective trials. Findings Bladder SmCC is more frequent in men and usually appears in the seventh to eighth decades. Macroscopic hematuria is the most common clinical symptom. The diagnosis of SmCCB is performed based on the same criteria determined by the WHO classification for the diagnosis of small cell lung carcinoma (SCLC). Prognosis is closely correlated with the stage at presentation. Although the prognosis of the disease is poor, a long survival can be achieved particularly by radical surgery following neoadjuvant chemotherapy in patients with early stage tumors. Cystectomy is still the current standard local treatment. However, cystectomy alone is not sufficient. Chemotherapy and definitive radiotherapy should be preferred for limited disease in patients who are not candidate for surgery. Conclusion Considering the poor prognosis of the disease, further studies are needed to determine the optimal treatment options and new molecular markers in the way of early diagnosis and favorable outcomes. Prospective, multicenter, randomized studies are required to evaluate the role of neoadjuvant chemotherapy followed either by surgery or radiotherapy.

Cytomorphologic features and differential diagnosis of neoplasms with small cell features in liquid-based urinary tract cytologic specimens

INTRODUCTION

Urinary tract cytology (UTCy) allows the accurate diagnosis of high grade urothelial carcinoma. Rare malignancies characterized by the presence of small cells may be more difficult to recognize, however. The aim of this study was to review our experience with liquid-based (ThinPrep) UTCy specimens showing small atypical cells and characterize their cytomorphology, potential differences from previously reported morphologic features, and discuss their differential diagnostic considerations.

MATERIALS AND METHODS

Among 18,859 UTCy specimens reviewed during a 13-year period (2001-2012), we identified 13 cases corresponding to surgical pathology specimens diagnosed as small cell carcinoma (6), melanoma (3), lymphoma (3), and leukemic involvement of the urinary tract (1). We recorded the original diagnoses made on these cases and 10 cytomorphologic features that could aid in their diagnosis.

RESULTS

We identified 13 cases in UTCy of 7 men and 6 women; 11 of which were diagnosed as positive or suspicious for malignancy. In 8 out of 13 cases (62%) the type of malignancy was correctly reported. Of the 10 recorded features, cellular clustering and nuclear molding were seen only in small cell carcinoma, whereas prominent nucleoli and an inflammatory background or diathesis were noted in lymphoma and melanoma cases. Intracellular pigment and multinucleation were recorded in melanoma cases.

CONCLUSION

The presence of small atypical cells in liquid-based UTCy should raise the suspicion of underlying malignancy involving the urinary tract. Cell clustering, nuclear molding, and hyperchromasia are helpful hints for the diagnosis of small cell carcinoma and the presence of small atypical cells with prominent nucleoli raises the possibility of lymphoma or melanoma.

Distinct genetic alterations in small cell carcinoma from different anatomic sites

Small cell carcinoma (SmCC) is a distinct clinicopathological entity first described in the lung. It represents approximately 15% of all bronchogenic carcinoma. Extrapulmonary small cell carcinoma (EPSmCC) morphologically indistinguishable from small cell lung cancer (SCLC) was first reported in 1930. Since its first description, EPSmCC has been reported in virtually all anatomical sites, including: gynecologic organs (ovary and cervix); genitourinary organs (urinary bladder and prostate); the gastrointestinal tract (esophagus); skin (Merkel cell carcinoma) and head and neck region. Regardless of the anatomic sites, all SmCCs have similar, if not identical, histo-pathology features and immunohistochemical profile. SmCC is one of the most aggressive malignancies. The molecular mechanisms underlying its development and progression remain poorly understood. Herein, we reviewed the literature in SmCC in respect to its site of occurrence, clinical features, immunohistochemical characteristics. SmCCs have heterogeneous molecular mutations. Dinstinct genetic alterations associated with SmCC from different body sites were reviewed. Some genetic alterations such as RB1, TP53 are commonly seen in different origins of SmCC. Other genes with site specificity were also summarized, such as bladder SmCC with TERT promoter mutations; prostate SmCC with ERG translocations; ovarian SmCC with SMARCA4 mutations; Merkel cell carcinoma (skin) and cervical SmCC with Merkel cell polyomavirus (MCV or MCPyV) and human papillomavirus (HPV). Further studies are needed to employ a genetically oriented approach for the diagnosis and therapy of SmCC.

Partial cystectomy in a 76 year old patient suffering from small cell carcinoma of the urinary bladder

Small cell carcinomas of the urinary bladder originating from the neuroendocrine cells are extremely rare. We present a case of a 76–year–old patient with small cell carcinoma of the urinary bladder. The patient had hematuria and cystoscopy revealed a tumor located in a urinary bladder diverticulum. Partial resection of the bladder wall with diverticulectomy was performed. Microscopic examination established the diagnosis of neuroendocrine carcinoma, which was confirmed by immunohistochemistry. Three–month follow–up showed no recurrent disease. Patient refused further chemotherapy and radiotherapy.

Large cell neuroendocrine carcinoma of the urinary bladder: case report and review

INTRODUCTION

Neuroendocrine carcinomas of the urinary bladder are relatively rare, accounting for less than 1% of all bladder carcinomas. These tumors can be divided into the more indolent typical or atypical carcinoid tumors and the aggressive small cell and large cell neuroendocrine carcinomas.

OBJECTIVE

To report 2 clinical cases of large cell neuroendocrine carcinoma of the bladder (LCCB) and to review the epidemiology, prognosis, and current treatment algorithms for patients with bladder small and large cell neuroendocrine carcinomas.

RESULTS

In both cases hematuria was the presenting symptom. One patient was submitted to partial cystectomy and the other to trans-urethral resection of the bladder tumor. The former patient died on the third month postoperatively. The latter patient had extensive liver metastasis at the time of diagnosis and died from acute liver failure on the 14th postoperative day. In review LCCB is associated with a more aggressive behavior and poorer prognosis than transitional cell bladder carcinoma. No standard approach exists. Surgery (transurethral ressection, partial cystectomy, radical cystectomy), chemotherapy and radiotherapy are current treatment modalities.

CONCLUSION

LCCB is an aggressive tumor which usually presents itself in an advanced stage. Neoadjuvant chemotherapy with platinum regimen plus aggressive surgical approach should be the treatment of choice.

Small cell carcinoma of the urinary bladder and prostate: Cytological analyses of four cases with emphasis on the usefulness of cytological examination

The occurrence of small cell carcinoma in the urinary bladder and prostate is rare. Only a few reports on the cytological features of small cell carcinoma of the urinary bladder in the urine specimen have been documented and, moreover, the urinary cytological features of prostate small cell carcinoma have been rarely reported. In this study, we analyzed the cytological features of four cases of small cell carcinoma of the urinary bladder and prostate, and discussed the usefulness of cytological examination of urine specimen for this type of tumor. This study included two urinary bladder and two prostate small cell carcinoma cases. Analyses of the cytological features of these cases revealed the following: i) the background was mostly inflammatory and necrotic material was also occasionally observed; ii) numerous tumor cells were present in two cases, whereas only a few neoplastic cells were observed in the remaining cases; iii) the neoplastic cells were small in size, had scant cytoplasm and a high nuclear/cytoplasmic ratio, and were arranged in small clusters or occasionally as single cells; iv) the tumor cell clusters showed prominent nuclear moldings; and v) the nuclei of the neoplastic cells were round to oval in shape with finely granular chromatin containing inconspicuous nucleoli. The cytological features of small cell carcinoma in the urine specimen are characteristic. Therefore, careful observation of the urine specimen may lead to a correct diagnosis of small cell carcinoma of the urinary bladder and, moreover, cytodiagnosis of prostate small cell carcinoma may also be possible.

Urinary cytomorphology and clinical correlates of prostatic small cell neuroendocrine carcinoma

BACKGROUND

Small cell carcinoma (SCC) of the prostate represents a rare form of prostatic carcinoma. While the tumor is often considered to arise from neuroendocrine proliferation or possibly dedifferentiation of an acinar carcinoma, the precise etiology remains uncertain. The diagnosis of prostatic SCC in urine has to date not been described.

METHODS

A retrospective review was performed at a tertiary-care hospital, and 3 patients with prostatic SCC in voided urinary specimens were identified. The following clinical data were collected for each case: age, gender, treatment and follow-up information, when available.

RESULTS

The patient age range was 70-86 years, all male. Two patients had known metastatic adenocarcinoma of the prostate, and 1 had recently presented with prostatic SCC. One patient with metastatic disease died shortly after diagnosis, the other was lost to follow-up. The third patient with a recent presentation has yet to have a treatment plan finalized.

CONCLUSIONS

Our results highlight the importance of making this uncommon diagnosis as it may carry significant treatment and prognostic importance. Future work should hopefully clarify the role of ERG gene rearrangements in the pathogenesis of prostatic SCC, as there is a potential role here for targeted therapy.

Development and characteristics of preclinical experimental models for the research of rare neuroendocrine bladder cancer

PURPOSE

For rare cancers such as neuroendocrine bladder cancer treatment options are limited due partly to the lack of preclinical models. Techniques to amplify rare primary neuroendocrine bladder cancer cells could provide novel tools for the discovery of drug and diagnostic targets. We developed preclinical experimental models for neuroendocrine bladder cancer.

MATERIALS AND METHODS

Fresh tumor tissue from 2 patients with neuroendocrine bladder cancer was used to establish in vitro and in vivo models. We analyzed additional archived tissues in the National Center of Tumor Diseases tissue bank from patients with neuroendocrine bladder cancer. Primary tumor samples were collected during radical cystectomy. PHA-665752 was used to inhibit MET in animal models and cell cultures. The expression of markers and drug targets in neuroendocrine bladder cancer was determined by flow cytometry. The growth of neuroendocrine bladder cancer in vitro was determined by counting live cells. Tumor growth in mice was assessed by measuring tumor volume. Groups were compared using the nonparametric Kruskal-Wallis test.

RESULTS

Xenograft models and serum-free cultures of neuroendocrine bladder cancer cells allowed screening for cell surface markers and drug targets. We found expression of the HGF receptor MET in neuroendocrine bladder cancer cultures, xenograft models and primary patient sections. The growth of neuroendocrine bladder cancer spheroids in vitro depended critically on HGF. Treatment of neuroendocrine bladder cancer bearing mice with a MET inhibitor significantly decreased tumor growth compared to that in control treated mice.

CONCLUSIONS

Neuroendocrine bladder cancer xenografts and serum-free cultures provided suitable models in which to identify diagnostic markers and therapeutic targets. Using the models, we noted HGF dependent growth of human neuroendocrine bladder cancer and identified MET as a new treatment target for neuroendocrine bladder cancer.

Small cell bladder cancer: biology and management

Small cell bladder cancer (SCBC) is a rare and aggressive form of bladder cancer. It exhibits similar biological behavior to small cell lung carcinoma. Untreated, it is associated with a very poor prognosis. Appropriate oncologic surgery remains the mainstay of treatment of this disease but is not curative alone in the majority of the cases. Adding systemic therapy to the treatment regimen has been shown to improve survival. The most common chemotherapy regimens used in published series include a platinum complex plus etoposide, although doxorubicin-based regimens and standard urothelial cancer regimens also have been associated with response. Despite robust chemotherapy responses, metastatic disease is associated with relapse and a median overall survival of 18 months or less. Better understanding of the molecular alterations driving SCBC may facilitate the development of new therapeutic strategies and improved outcomes.

Primary small cell carcinoma of the urinary bladder--mini-review of the literature

Primary small cell carcinoma of urinary bladder is a rare but aggressive disease with poor prognosis and a high mortality rate. It accounts for less than 1 % of all the primary cancers seen in the urinary bladder. Diagnosis and management of this entity poses a challenge to the clinician due to the lack of a standardized protocol for its treatment. Herein we discuss primary small cell carcinoma of the urinary bladder in its entirety.

Primary metastatic neuroendocrine small cell bladder cancer: a case report and literature review

Small cell carcinoma of the urinary bladder (SCCUB) is a rare variant of neuroendocrine nonepithelial tumor. Clinically, SCCUB appears like a flat or ulcerated lesion and microscopically can cause microvascular invasion and necrosis. Small cell cancer, rarely found in the urogenital tract in a primitive form, usually coexists with urothelial bladder cancers. It has an incidence of 0.35-0.7% of all bladder neoplasms and survival at 5 years is estimated to be around 8%. A 60-year-old man who was a smoker was referred to our department with episodes of gross hematuria and pain in the lumbar region. After an extensive transurethral resection of the bladder, including of the muscular layer, the diagnosis of small cell carcinoma of the bladder was made. The neoplastic cells were positive with immunohistochemical staining for chromogranin A, paranuclear reactivity to cytokeratin and neuron-specific enolase. A total-body CT scan revealed lymph node involvement and hepatic, adrenal and lung metastases. Because of the advanced stage it was decided to avoid radical cystectomy and perform chemotherapy. The patient underwent two different cycles of cisplatin chemotherapy following international recommendations, but unfortunately without any response. After palliative therapy, the patient died in January 2010.

A rare bladder cancer--small cell carcinoma: review and update

Small cell carcinoma of the bladder (SCCB) is rare, highly aggressive and diagnosed mainly at advanced stages. Hematuria is the main symptom of this malignancy. The origin of the disease is unknown; however the multipotent stem cell theory applies best to this case. Histology and immunohistochemistry shows a tumour which is indistinguishable from small cell lung carcinoma (SCLC). Coexistence of SCCB with other types of carcinoma is common. The staging system used is the TNM-staging of bladder transitional cell carcinoma. The treatment is extrapolated from that of SCLC. However, many patients with SCCB undergo radical resection which is rarely performed in SCLC. Patients with surgically resectable disease (< or = cT1-4aN0M0) should be managed with multimodal therapy associating chemotherapy, surgery and/or radiotherapy. Neoadjuvant chemotherapy using four chemotherapy cycles followed by radical cystectomy is the most effective therapeutic sequence. Patients with unresectable disease (> or = cT4bN+M+) should be managed with palliative chemotherapy based on neuroendocrine type regimens comprising a platinum drug (cisplatin in fit patients). The prognosis of the disease is poor mainly in the case of pure small cell carcinoma. Other research programs are needed to improve the outcome of SCCB.

A pure microcytic bladder carcinoma synchronous to prostatic adenocarcinoma

Small cell carcinoma (SCC) or microcytic carcinoma of the urinary bladder is a rare entity comprising approximately 0.5% of all bladder tumors. Due to its rarity, no prospective studies evaluating the most effective treatment have been published in the medical literature. Several cases of bladder SCC have been presented so far. We describe our case report and we revise the recent literature. Our patient was diagnosed with pure bladder SCC and prostatic adenocarcinoma. After the initial and complete transurethral resection of the bladder tumour (TUR-BT), he underwent a thorax and mediastinum computer tomography (CT) examination to exclude primary pulmonary small cell carcinoma and a bone scan scintigraphy for staging purposes. He received a three 14-day cycles of Cisplatin-containing chemotherapeutic schema and a single dose of Luteinizing-Hormone Releasing hormone (LHRH) analogue injection after 14 days of bicalutamide administration. The patient is followed for 24 months without any signs of bladder SCC recurrence or biochemical or local relapse from prostatic adenocarcinoma.

[Small cell neuroendocrine carcinoma of the bladder: A case report and review of the literature]

Neuroendocrine small cell carcinoma of the bladder is a rare and aggressive cancer with a very pejorative behavior. Neuroendocrine small cell carcinoma of bladder is a histological entity with special characteristics, rapidly aggressive and metastatic and with a poor prognosis. Because it is rare, there is no consensus to date. Its management should be multidisciplinary, involving surgery, chemotherapy and radiotherapy. We report the case of an 84-year-old patient with neuroendocrine small cell carcinoma of the bladder, treated by neoadjuvant chemotherapy followed by a combined chemoradiotherapy. A review of the literature on this topic is also presented.

Small cell carcinoma of the upper urinary tract (UUT-SCC): report of a rare entity and systematic review of the literature

BACKGROUND

Primary small cell carcinoma of the upper urinary tract (UUT-SCC) is an extremely uncommon disease. The current knowledge of these rare tumors is mainly based on case reports or small series.

METHODS

We reported two cases and performed a systematic literature search from 1970 to 2010 for articles on UUT-SCC. Overall, 40 patients with UUT-SCC were reviewed, a database was generated to analyze clinical characteristics, pathological features and therapy outcomes and to attempt in identifying prognostic factors.

RESULTS

For the 39 cases with available data, median age was 66.5 years and male-female ratio was 2:1. An Asian ethnic background was more common (59%). Surgery was the standard treatment given to all patients. In 67% of cases, SCC coexisted with another malignant component, including urothelial carcinoma in 62% of patients. Overall median survival was 15 months and the 1-, 2- and 3-year survival rates were 58.4%, 38.1% and 23.8%, respectively. Of all cases, 53.8% developed detectable metastasis in a median delay of 13 months. Pathological stage was the only significant prognostic factor found (p=0.01). Patients who received adjuvant chemotherapy seem to have a higher median survival comparatively to those who did not receive chemotherapy but this was not statistically significant (24 vs. 12 months, p=0.56).

CONCLUSIONS

UUT-SCC is an extremely rare tumor characterized by an aggressive clinical course. Local or distant metastases are frequent and survival is poor. Pathological stage appeared to be a prognostic factor for overall survival.

Neuroendocrine Small-Cell Bladder Cancer: Our Experience

Introduction

Neuroendocrine bladder cancer is extremely rare, with an estimated incidence of 0.35–0.70% of all bladder tumors. The small-cell carcinoma represents the most frequent histologic variant described. Small-cell carcinoma is an epithelial tumor associated with a more aggressive behavior and poorer prognosis than transitional cell bladder carcinoma. The overall survival rate at 5 years does not exceed 8%. At the time of presentation 59% of patients have clinical stage >T2 and 56% show metastatic disease. In 50% of the patients, fatal progression occurrs within 6 months. Local recurrence after radical surgery occurred in 50–70% of cases.

Patients and Methods

We report three cases of pure neuroendocrine small-cell bladder cancer. Hematuria was the most common presenting symptom. Local advanced disease was present in all the cases with stage >T2, metastatic disease in 1 case, lymph node involvement and ureteral bilateral obstruction in 2. Two patients were treated by radical cystectomy, bilateral pelvic limph node resections and urinary derivation. Platinum-based adjuvant chemotherapy was proposed but only two patients received the treatment. One patient with liver metastasis was managed only by extensive TUR and support regimen.

Results

In 2 patients residual or relapsed cancer reappered within 2 months after surgery. All of the three patients died of metastatic disease at 5, 7, and 13 months. Median overall survival was 7 months. The most common site of relapse and spread of disease was the peritoneum and intestinal tract, and the reason of death was uncontrolled acute hemorrhage from gastro-intestinal district.

Conclusions

In the absence of a prospective study, and because of the rarity of the disease, the best treatment for small-cell bladder cancer remains uncertain. Neoadjuvant chemoterapy with platinum regimen plus aggressive surgical approach will be the treatment of choice. The association of chemotherapy and radiotherapy should also be considered.

Clinical and therapeutic aspects of extrapulmonary small cell carcinoma

Extrapulmonary small cell carcinoma (EPSCC) is usually treated similarly to small cell lung cancer. Differences in aetiology, clinical course, frequency of brain metastases, and survival, however, warrant a differential therapeutic approach. In this review, we focus on the treatment of the most predominant sites of origin of EPSCC; the gastrointestinal tract, the genitourinary tract, the head and neck region, and small cell carcinoma of unknown primary. Furthermore we review the available data concerning the controversial issue of prophylactic cranial irradiation (PCI) after optimal treatment of EPSCC. We found in the literature a significant lower incidence of brain metastases in EPSCC as compared to pulmonary small cell carcinoma when PCI is omitted and therefore we do not recommend PCI. An exception is EPSCC originating from the head and neck region which is associated with a higher incidence of brain metastasis, justifying addition of PCI.

Small cell carcinoma of the urinary bladder--histogenesis, genetics, diagnosis, biomarkers, treatment, and prognosis

Small cell carcinoma of the urinary bladder is a rare but highly aggressive malignancy with a dismal prognosis. Most patients present with advanced disease at the time of diagnosis. Hematuria is the most frequent presenting symptom. Histologically, small cell carcinoma of the urinary bladder is indistinguishable from its pulmonary counterpart. Coexistence with other types of carcinoma is common. Histogenesis is uncertain; there are several competing theories, including origin from stem cells, from urothelial cells, and from neuroendocrine cells in normal or metaplastic urothelium. The molecular pathogenesis remains unclear. Immunohistochemical staining can be extremely helpful in establishing the diagnosis, and in investigating the use of potential therapeutic strategies. Currently, combinations of surgical resection, chemotherapy, and radiation therapy represent the main treatment options. The recent observation of c-kit and epidermal growth factor receptor expression in more than 25% of patients with urinary bladder small cell carcinoma opens new avenues for further investigation. Improvement in survival may depend upon the identification of new molecular markers to facilitate earlier diagnosis and the development of novel targeted therapies. In this paper, we review general aspects of small cell carcinoma of the urinary bladder, focusing on the ways in which our understanding of this entity has been positively influenced by studies of the histopathologic and immunohistochemical findings, and by investigations of genetic alterations in this disease.

Small-cell carcinoma of the urinary bladder: diagnosis and management

Small-cell carcinoma of the urinary bladder (SCCUB) accounts for less than 1% of all cancers arising in the urinary bladder. Current diagnosis and management of SCCUB are often patterned after small-cell lung cancer (SCLC). However, SCCUB therapy is different from that for SCLC. For example, many patients with SCCUB undergo local resection, which is rarely performed in SCLC. As in SCLC, platinum-etoposide combination chemotherapy is employed as the main systemic treatment option for SCCUB. Chemotherapy is usually combined with other therapeutic modalities, especially in patients whose disease is limited to the locoregional area. Owing to the rarity of this malignancy, no prospective study has been performed that establishes the efficacy and duration of chemotherapy or the relative efficacy of platinum-etoposide versus other chemotherapeutic regimens. This article provides a comprehensive review of the current status of SCCUB diagnosis and management, as well as some unique insights into this rare tumor.

Extrapulmonary Small Cell Carcinoma of the Bladder

Among the many sites for primary small cell cancer is the genitourinary system. The majority of cases have been observed in the bladder and prostate. Small cell carcinoma accounts for less than 1% of all bladder tumors. Definitive predisposing factors are unknown; however, small cell carcinoma of the bladder has been associated with cigarette smoking, long-standing cystitis, bladder calculus, and augmented cystoplasty. Contrary to the early theory of derivation from Kulchitsky cells, it is now believed that small cell carcinoma of the bladder originates from the totipotent stem cells present in the submucosa of the bladder wall. A number of chromosomal aberrations have been reported in small cell cancer of the bladder. There are no specific clinical features that differentiate these patients from transitional cell carcinoma of the bladder; however, some patients may have associated paraneoplastic conditions. Diagnosis is established by cystoscopic-assisted biopsy. Like small cell carcinoma of the lung, small cell carcinoma of the bladder has a propensity for early metastases. There is no standard therapy for small cell carcinoma of the bladder and the prognosis is poor; however, patients treated with cisplatin-based chemotherapy regimens seem to have a better prognosis.

Clinical review – Small cell carcinoma of the bladder

OBJECTIVES

To review the published literature on the diagnosis and management of small cell carcinoma of the bladder (SCCB).

METHODS

Papers were identified by searches of PubMed using the terms "small cell", "bladder" and "carcinoma". Additional papers were identified from review of references of relevant articles.

RESULTS

SCCB comprises less than 1% of bladder malignancies. It is an aggressive tumour that commonly presents at an advanced stage, in an elderly population. Consequently, patients are often not fit for anti-neoplastic therapy. In fit patients, the bedrock of treatment in the majority of cases is platinum-based systemic chemotherapy, which was the only factor predictive of improved outcome on multivariate analysis in one large review. The use of neoadjuvant chemotherapy has been associated with favourable results and may therefore be the preferred approach when scheduling treatment. Options for local management comprise surgery or radiotherapy (sequentially or concurrently with chemotherapy), both of which are potentially curative in selected cases. However, the subsequent frequent development of urothelial malignancies with bladder-sparing approaches should be considered when planning treatment, particularly in younger patients. Prognosis of SCCB overall is poor, the median survival of all cases varies from 4 to 23 months, and overall survival at 5 years from 10% to 40% of patients.

CONCLUSIONS

SCCB is a rare and aggressive tumour with a poor prognosis. Future efforts should be directed at its early detection and the development of more effective systemic therapies.

[Small cell neuroendocrine tumour of the bladder: with reference to a case and bibliographical revision]

INTRODUCTION AND OBJECTIVES

The small cell neuroendocrine tumour is an infrecuent neoplasia, with inmunohistochemistry being the key to diagnosis. We present a new case making reference to treatment and its evolution there after.

MATERIAL AND METHODS

The clinic, diagnosis and treatment of this tumour is described. Bibliographical revision follours.

CONCLUSIONS

The neuroendocrine tumour of small cell is an infrecuent neoplasia, in which the inmunohistochemistry study is key in the diagnosis. The differential diagnosis includes the high degree diferentiation transitionals cells carcinoma and primary and secondary linfoma. The standard treatment is based on chemotherapy plus surgery.

Small Cell Carcinoma of the Bladder: A Case Report and Review of the Literature

Primary pure small cell neuroendocrine carcinoma of the bladder is a rare condition. It is an aggressive tumor with an average five-year survival rate of less than 10% as cited by multiple case reports. We report a 48 year-old male patient with primary small cell neuroendocrine carcinoma of the bladder who was treated with TUR-T, adjuvant carboplatin-based chemotherapy and radiotherapy. The patient is free of disease at the end of 30 months with a normally functioning bladder.

Primary small cell neuroendocrine carcinoma of the urinary bladder with coexisting high-grade urothelial carcinoma: a case report and a review of the literature

Primary neuroendocrine carcinomas of the urinary bladder are rare. Here, we report a case of an 82-year-old man who presented with hematuria and was found to have an ulcerated lesion in the bladder. A diagnosis of small neuroendocrine cell carcinoma with coexisting minor high-grade urothelial components was rendered. In this report, the clinical, cytological, histological, and immunohistochemical features of this case are described, and a review of the literature about this neoplasm is presented. The differential diagnoses of small cell tumor in urinary bladder washing specimens are discussed.

Small cell carcinoma of the urinary bladder. The Mayo Clinic experience

BACKGROUND

Small cell carcinoma (SCC) of the urinary bladder accounts for 0.35-0.70% of all bladder tumors. There is no standard approach to the management of SCC of the urinary bladder.

METHODS

The authors performed a retrospective study at Mayo Clinic (Rochester, MN) to characterize the clinical and pathologic features of patients with SCC of the urinary bladder diagnosed between 1975 and 2003 with emphasis on management.

RESULTS

Forty-four patients were identified who had primary bladder SCC, 61.4% of whom had pure SCC. The male:female ratio was 3:1, the mean age was 66.9 years, and the mean follow-up was 3.2 years. Twelve patients (27.3%) had Stage II disease, 13 patients (29.6%) had Stage III disease, and 19 patients (43.2%) had Stage IV disease. The overall median survival was 1.7 years. The 5-year survival rates for patients with Stage II, III, and IV disease were 63.6%, 15.4%, and 10.5%, respectively. Six of eight patients with Stage II bladder SCC achieved a cure with radical cystectomy. Five patients with Stage IV disease had obvious metastases and received chemotherapy. Fourteen patients underwent radical cystectomy and were diagnosed later with locally advanced disease (T4b) or lymph node metastasis (N1-N3; Stage IV disease). Only 2 of 19 patients with Stage IV disease who received adjuvant chemotherapy were alive at 5 years.

CONCLUSIONS

Patients with bladder SCC should undergo radical cystectomy except when metastatic disease is present (M1), in which case, systemic chemotherapy is indicated. Adjuvant treatment is not indicated for patients with Stage II disease after radical cystectomy but should be considered for patients with Stage III and IV disease. Chemotherapy should be a platinum-based regimen.

Small cell carcinoma of bladder: a single-center prospective study of 25 cases treated in analogy to small cell lung cancer

OBJECTIVES

To evaluate the feasibility and efficacy of a therapeutic algorithm for the management of small cell carcinoma of the bladder derived from the treatment of small cell lung cancer.

METHODS

During a 10-year period, 25 patients (23 men and 2 women; median age 64 years, with 8 [32%] older than 75 years) with small cell carcinoma of the bladder were defined as having limited disease (LD) or extensive disease (ED) in analogy to the classification of small cell lung cancer. Patients with LD were eligible for chemotherapy and sequential radiotherapy. Patients unfit for chemotherapy were offered complete transurethral resection and radiotherapy or cystectomy for large symptomatic tumors. Patients with ED were offered palliative chemotherapy.

RESULTS

Of the 25 patients, 17 (68%) had LD and 8 (32%) ED. Without regard to stage, the median survival of those receiving chemotherapy was 15 months versus 4 months for those who did not. The median survival for those with LD was 12 months versus 5 months for those with ED. Nine patients (52.9%) with LD could not undergo chemoradiotherapy because of comorbidity and reduced performance (n = 7), progression (n = 1), or drug-related death (n = 1). Five of those patients underwent TUR and radiotherapy and two cystectomy.

CONCLUSIONS

The prognosis of small cell carcinoma of the bladder is poor. This treatment algorithm offers bladder sparing for most patients, with few long-term remissions in patients with small, confined tumors. None of the patients died of locoregional tumor progression, supporting that cystectomy is not the treatment of choice for those with LD. With a significant proportion of elderly patients with comorbidities, chemoradiotherapy was not feasible in more than one half of the patients with LD.

Small cell carcinoma of the bladder: a contemporary clinicopathological study of 51 cases

AIMS

We present 51 cases of primary small cell carcinoma of the bladder in a clinicopathological study with emphasis on features that aid in the initial recognition and diagnosis of small cell carcinoma of the bladder.

METHODS AND RESULTS

The patients were 40 men and 11 women between the ages of 39 and 87 years (mean age 67 years). Clinical data were available in 41 cases. The most common symptomatology was haematuria in 63% of the patients while dysuria was present in 12%. Thirty-eight patients were caucasians; seven patients were Hispanics; two patients were Asian; one patient was African-American; in the three additional patients no racial information was obtained. Biopsy material was obtained in all of the patients. Cystectomy was performed in 20 patients. At diagnosis, clinical stage was as follows: stage I in two (5%), stage II in 18 (44%), stage III in 10 (24%), and stage IV in 11 (27%). Histologically, urothelial carcinoma was present in 70% of the cases, adenocarcinoma in 8%, and squamous cell carcinoma in 10% of the cases. Small cell carcinoma was the only histology present in only 12% of the cases studied. Immunohistochemical studies using chromogranin, synaptophysin and chromogranin were positive in 30-70% of the cases.

CONCLUSIONS

The present study highlights the unusual phenomenon of pure small cell carcinoma of the bladder and its association with other non-small cell carcinomas in that anatomical location. In addition, the study highlights the different modalities employed to treat patients in whom there is a component of small cell carcinoma of the bladder.

Small-cell carcinoma of the urinary bladder. A clinico-pathological study of ten cases

Small-cell carcinoma (SCC) of the urinary bladder is an infrequent neoplasia accounting for 0.5% of all tumors located at this level. There is a predilection for males over females with a 4:1 proportion and a median age of 66 years. In most cases, the initial diagnosis is made at the metastatic or progressive stage of the disease. For this study, we collected ten cases of SCC of the urinary bladder, diagnosed over a period of 16 years, to describe the morphological and immunocytochemical characteristics of these infrequent neoplasia. In all cases, clinical data such as age at presentation, personal background, clinical symptoms, stage, treatment, clinical outcome and present status were available. Primary antibodies included chromogranin, neuron-specific enolase, synaptophysin, PGP 9.5, HNK-1, cytokeratin 34betaE12, cytokeratin 20, thyroid transcription factor-1 (TTF-1), c-erbB2 (CB-11), p53 (DO7), and Ki67 (MIB-1). In addition to the expression of neural/neuroendocrine markers, immunostaining for p53 and c-erbB2 was found in 80% and 50% of cases, respectively. In this paper, we confirm the aggressive course of the neoplastic disease. The expression of c-erbB2 in 50% of cases opens up hypothetical new possibilities for the use of immunotherapy in such cases.

Primary small cell neuroendocrine carcinoma of urinary bladder: an uncommon entity to be recognized

INTRODUCTION

To describe the clinical presentation, diagnosis and treatment outcome of neuroendocrine carcinoma of urinary bladder.

METHODS

Clinical and pathological findings of 11 patients with diagnosis of small cell neuroendocrine tumour (SCNE) of urinary bladder are reviewed between Jan. 1991 to Jan 2001. Clinical data including age, sex, presenting symptoms, clinical stage at presentation, modality of treatment and outcome were determined. Sections of the tumour were studied by immunohistochemical methods using various antibodies to determine neuroendocrine pattern.

RESULTS

Patient age ranged from 35 to 79 years (mean 60 years). The clinical presentation included, gross hematuria 6, increased urinary frequency and dysuria 3, hydroureteronephrosis with flank pain 2. 3 patients had open exploration for presumed bladder stones by suprapubic route. Undifferentiated carcinoma was the initial report in 2 and associated transitional cell carcinoma in 2 cases. Urinary cytology obtained in 4 patients showed poorly differentiated carcinoma. Immunohistochemistry showed in all cases. 7 patients had radical cystoprostatectomy with adjuvant chemotherapy and 4 patients had combination of chemotherapy and radiotherapy. The survival ranged from 6 months to 30 months (mean 16.5 months).

CONCLUSION

Primary small cell neuroendocrine carcinoma of urinary bladder is an aggressive malignancy with poor long-term outcome. Awareness of clinical presentation with free application of immunocytochemistry is emphasized to diagnose this unusual malignancy at earliest.